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APPLICATION FOR SANITATION PERMIT Permit _----- (Complete in Duplicate) „ 3 Date Issued 1.r2_-.__l--___-•- Application is hereby made to the San Joaquin Local Health District fora permit to construct a.nd install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---------------- � e°l77D_ -------- - r-------------------------------- e Owner's Name------------------------ / -. ------- ---------------------- Phone------------------------------------ Address------------------------------------------------------------ -----------------------------------Address----------•------•--;--------------------------------------�1� �--44 - -----------------_----------------------------------------------------------- Contractor's Name----------------------------_ 11--- Phone-=fp .0FW_4' ---------- Installation will serve: Residence 5C Apartment House 19, Commercial ❑ Trailer Court ❑ Motel ❑ Other E] Number of living units:,____ Number of bedrooms =/ Number of baths___ Lot size __f +_ __�_4_P----_------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe„: Hardpan ❑ Previous Application Made: YesNo E] New Construction: Yes El No `ti� TYPE OF INSTALLATION AND SPECIFICATIONS: V (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Tank: Distance from nearest well-----------------Distance from founda;ion--------------------.Material ----------___-- ---_-.__--.-_--__----.----_._,_. . No. of compartments-- Size--------------------------------Liquid depth----------------- --------Capacity-------------------- Disposal Field: Distance from nearest welii_i .._.Distance from foundation_-2-------------- Distance to nearest lot line---------------- Number of lines______________��_,,�� _ Length of each line___ `'p_ ______.Width of trench_ _ -------.-_---_-_---- Type of filter material_ }__N__ ____Depth of filter material____.��____-------Total length_.��_-.-____-_--_____ ------------- e epage P•t: Distance to nearest well-------------__- .__Distance from foundation--------------------Distance to nearest lot line----_-_-__._-____ 4 Number of pits---------------------Lining material----------------------.Size: Diameter---.-------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---.---------------.Lining material----_-------_----__---_-------______-. ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity------------------------_--gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------;-------------------- Distance -____--- _______- Distanceto nearest' lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe]' ---------- ----------- ---------- = -------------------------- r tt�fei'el------------------------- ,r� r -----------------------------------------------•--------•-----------------------------------------------------.---------------------•-------------- ----------------------------....---------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County F ordinances, State laws, d egulations of th quin Local Health District. /{ / � f €�/ Contractor) (Signed) � L "�j ------------------------- { Y� •/�l,- --------------------(Title) {Plot plan size of lot, location of system n relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------- DATE --------------------------------------------------- REVIEWEDBY---------------------------------- .��_ __�--------------------------- ---------------------------------------------- DATE----- -------------------•----------------------- { BUILDING PERMIT ISSUED_--------------------------------------------------------------------------------------------------- DATE---- ----------------------------------------- - Alterationsand/or recommendations--------------------------------------------------------------------------------------------•------------------------------------------------------ --------------------- -------------•-------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ------------ --•-------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------- ------------- --------------------------------------------------------------------------- ---- ----------------------- ----------------------- ---------------------------------------------------------------- - � � FINAL INSPECTION BY: Date -- ----------- 1- - - ---- -------- ------------ _'�._ - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manfeca, California Tracy, California t ES-9-2M 8-51 Revised W-2100